Has any license/certification been subject to disciplinary action or investigated?

YesNo

If yes, Explain:

List all states which you have an applied status for a license:

Date Applied:

/
/

Date Applied:

/
/

Date Applied:

/
/

Date Applied:

/
/

Date Applied:

/
/

Part 5: Education

Education level

Name/Location of School

Graduation Date (Month/Year)

Type of Diploma/Degree

College

/

Graduate School

/

Other School

/

Part 6: Employment History

Please fully complete the following section even if application is accompanied by
a professional resume.Starting with your most current job, list all positions held for the past ten (10)
years. Give current and correct telephone numbers and addresses.

Name of most current or recent employer

Address

City

State

Zip Code

Phone

(
)
-
ext

Supervisor Name

Supervisor's Title

Dates of Employment:

From:
/
/
To:
/
/

Starting Salary:

Final Salary:

Position Held:

Reason for Leaving:

Was this a temporary or travel assignment?

YesNo

If yes, which agency:

Job Responsibilities:

Name of second most recent employer

Address

City

State

Zip Code

Phone

(
)
-
ext

Supervisor Name

Supervisor's Title

Dates of Employment:

From:
/
/
To:
/
/

Starting Salary:

Final Salary:

Position Held:

Reason for Leaving:

Was this a temporary or travel assignment?

YesNo

If yes, which agency:

Job Responsibilities:

Name of third most recent employer

Address

City

State

Zip Code

Phone

(
)
-
ext

Supervisor Name

Supervisor's Title

Dates of Employment:

From:
/
/
To:
/
/

Starting Salary:

Final Salary:

Position Held:

Reason for Leaving:

Was this a temporary or travel assignment?

YesNo

If yes, which agency:

Job Responsibilities:

Personal references:

Name

Telephone

Occupation

1.

(
)
-
ext

2.

(
)
-
ext

3.

(
)
-
ext

Part 7: Upload your resume

Please attach you resume in an MSWord ".doc" or any other word processors
".rtf" file type by clicking the "Browse" button below.

Attach Resume:

Please read the following before submitting this application

I hereby certify that the information I have provided
in this application form is true and correct to the best of my knowledge. I understand
that if I am employed, any false, misleading or otherwise incorrect statements made
on this application or during my interviews may be grounds for my immediate discharge.I agree to allow Prime HealthCare Staffing to verify the
accuracy of all the information provided including contacting any company or individual
it deems appropriate to verify my employment history, character and professional
qualifications.I understand stand my employment with Prime HealthCare
Staffing is at will and may be terminated by myself or by the company at any time
for any reason or no reason, with or without prior notice.
I have read and agree to the above statements.